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SAN JOAQUIN COUNTY F11VI ) ONiVIENrA AL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID II SERVICE REQUEST # <br /> Retail Fuel (py / 5 ;4 (o 0 <br /> OWNER / OPERATOR <br /> Balblr Singh CHECK ifBILLING ADDRESS <br /> FACILITY NAME <br /> 76 Express Tiger No 1 <br /> SITEADDRESS5777 S I French Camp Rd Stockton 9 20 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Same Street Number Street Name <br /> CITY STATE zip <br /> PHONE #'I EXT, APN # LAND USE APPLICATION # <br /> (209 ) 9834781 <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Carrie Miller CHECK if BILLING ADDRESS15 <br /> BUSINESS NAME Elite IV Contractors PHONE # EXT, <br /> 09 461 -6337 <br /> HOME or MAILING ADDRESS 2 � '� 0. �- Fax # <br /> 7 ( 209-461 -6342 <br /> CITY 'V STATEOR zip 0 SZO5 <br /> BILLING ACKNOWLEDGEMENT: I , the undersigned property or business owner, operator or authorized agent of same , <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project Or <br /> activity will be billed to me or my business as identified on this form . <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes , Standards, STATE and FEDERAL laws. <br /> APPLICANT' S SIGNATURE : DATE : 2/8/2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT 0 Office Manager <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable , i , the owner or operator of the property located at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is provided to me Or <br /> my representative . PA leb <br /> TYPE OF SERVICE REQUESTED : u y WA 4 N <br /> COMMENTS : t' J I e ct b �J�Q S <br /> 9' <br /> 08 <br /> ?0 <br /> SA ti23 <br /> JO <br /> oti IN cot/ <br /> H dFP4 ��NT1` <br /> ACCEPTED BY : EMPLOYEE # : DATE: <br /> ASSIGNED TO : / jlp� �� _ �{/ EMPLOYEE M DATE: <br /> i .,. lam^ „r U ' <br /> Date Service Completed (if already completed) : — m SERVICE CODE: b _ �� S PIE : 3 �' <br /> Fee Amount : , l� � � Amount Pai �.�2' � Payment Date <br /> Payment Type 5 �- Invoice # Check # 154 93 11 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />